Children with ear, nose and throat problems often see paediatricians, general practitioners (GP) and ear, nose and throat (ENT) surgeons.
A particularly common scenario is a child aged four years who wakes up in the middle of the night crying because of ear pain. In medical parlance, this is a child with an acute earache.
The doctor would usually make a diagnosis of middle ear infection, or acute otitis media (AOM), and give some medications. The child usually gets better rapidly, and all is well within a few days – case closed.
The ear is more than just the pinna or auricle that we see jutting out of the sides of our heads. Imagine the ear in simple terms as three limbs of the letter Y, external, middle and inner.
The pinna and the ear canal make up the external ear, a hollow tube. The middle ear cavity is an air-filled hollow tube extending from the back of the nose and the nasopharynx to meet the ear canal at the eardrum.
The inner ear is another tube that starts from the brain and meets the middle ear just a centimetre behind the eardrum. The inner ear consists of the cochlea and the vestibular system (responsible for balance), and their nerves.
Infection of the middle ear
AOM is simply inflammation of the middle ear cavity, which is effectively a room upstairs from the nose in the same house. The causes of inflammation are almost always infection by viruses and bacteria from the nose climbing the “staircase” of the Eustachian tube to enter the middle ear.
Infection of the middle ear commonly starts out as viral in nature, or as part of a viral common cold, from which the child usually recovers, without further involvement of bacteria.
Occasionally, the viral infection lays the way for the entry of bacteria, which comes with the development of pus. When left untreated, several possible outcomes may ensue.
In many cases, many children get better spontaneously without treatment, because of a superior immune system that manages to defeat the bacteria.
In some cases, the eardrum may rupture and the ear discharges pus.
Rarely, the pus spreads from the middle ear space into the bone surrounding the middle ear, causing an abscess behind the pinna, known as acute mastoiditis, or into the brain above, causing meningitis or brain abscesses.
Otitis media can occur at any age, but as described above, I see quite a few at age four. This may be because children at this age are school-going and are therefore at higher risk of catching viral colds, increasing their risk of otitis media.
Why the pain peaks in the wee hours of the morning is a mystery. Perhaps, a reasonable explanation is that during the waking hours, constant eating and drinking helps to open the Eustachian tube regularly and drain some of the middle ear fluid.
During sleep, without any swallowing, the fluid builds up a steady head of pressure. The diagnosis of AOM is suspected simply from the symptoms volunteered by the child’s parent, amongst which are fever, pain, reduced appetite and activity levels, irritability or poor sleep.
The age of the child and a recent bout of the common cold adds weight to the diagnosis. Confirmation is done by looking for pus in the ear canal or at the eardrum, whose colour and appearance would suggest the diagnosis. Redness implies inflammation. A bulging white eardrum indicates pus inside the middle ear.
However, the situation is sometimes less than ideal. The struggling child prevents proper examination, or there is too much wax in the ear canal, preventing the doctor from seeing the eardrum. A crying child’s face is red due to a rush of blood, which similarly makes the eardrum appear red and inflamed when in fact it is not.
Underdiagnosis and overdiagnosis of infection
I have seen cases referred to me as ear canal wax impaction, which I thought was AOM in plain sight!
Some of these patients were prescribed wax softening drops, instead of painkillers or antibiotics. It is not the end of the world not to give painkillers, but it is still a knee-jerk blunder to assume wax impaction just because it is the first thing seen.
Wax sitting in the ear canal is a red herring, and does not cause pain by itself. On the other hand, I have also seen referrals of “acute otitis media” which clearly are not.
As mentioned above, a crying child’s eardrum may be red and appear inflamed, which is misleading, when in fact, the infection may be elsewhere – another example of a red herring.
Acute otitis externa refers to infection of the ear canal, whose symptoms are often pain and discharge, not dissimilar to otitis media. The pinna is sensitive to touch in cases of otitis externa, whereas pulling the pinna is acceptable in a child with otitis media.
Antibiotics and painkillers are usually given, which is also the correct prescription for otitis media.
Overdiagnosing AOM is not as big a deal as underdiagnosing. It may well be that “otitis media” is used as a catch-all term for all ear infections, regardless of external or middle ear.
Undertreating and overtreating AOM
Once the diagnoses of AOM has been made, treatment is usually prompt and appropriate. However, I have noticed some children are prescribed antibiotic ear drops instead of oral antibiotics.
This does not make sense, as a frequently intact eardrum will not allow the antibiotic solution to enter the middle ear. This mistake can be said to be under-treating if bacterial infection is suspected. I shall only highlight two issues that need attention.
Firstly, I have observed that many children are prescribed oral antibiotics when the child has only had pain and fever for a day. At this early stage, the organism is often a virus, which does not respond to antibiotics anyway.
There is intense debate going on in medical circles about the overuse and unnecessary use of antibiotics, in light of the very serious public health issue of the emergence of bacteria that are resistant to conventional antibiotics.
There exist excellent guidelines, especially from North America, based on the age of the child and severity of symptoms. These guidelines advise initial 48 hours of “watchful waiting”, and if necessary, the use of simpler antibiotics as the first-line treatment.
I cannot reproduce the guidelines in full, but essentially, children less than two years all need antibiotics, regardless of severity, and even uncertain diagnosis, of AOM.
Children older than two years and with lesser symptoms can be prescribed antibiotics, but on a case-to-case basis, after discussion with parents. I feel that these guidelines, which are non-obligatory anyway, can be applied to the Malaysian setting.
There are children whose parents cannot afford repeat visits, whether time-poor or money-poor, where antibiotics are justified, but the use of antibiotics does have side effects.
A doctor should weigh the risks and benefits of giving antibiotics on an individual case basis.
Secondly, I have been informed by pa- rents of some children having infrequent or first-ever episodes of AOM that they were advised to have surgery without even trying medication.
According to the same North American guidelines, the insertion of ventilation tubes (grommets) or surgery is mostly for frequently recurrent episodes of AOM, persistent pain not responding to antibiotics, serious brain involvement with pus, or for otitis media with effusion. The latter is a condition where mucous sits in the middle ear cavity for weeks on end, causing mild hearing loss.
Thus, it does not make sense to subject first-timers to the risks of surgery and the nuisance of having a tube in the eardrum.
This article is courtesy of the Malaysian Association of Paediatric Surgery. For further information, e-mail firstname.lastname@example.org. The information provided is for educational and communication purposes only and it should not be construed as personal medical advice. Information published in this article is not intended to replace, supplant or augment a consultation with a health professional regarding the reader’s own medical care. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information.